Hemarthrosis

What is Hemarthrosis?

Hemarthrosis is a condition where bleeding happens inside the joint space. Doctors may suspect this condition based on patients’ medical history, physical examination, and various imaging techniques. However, the most accurate way to confirm hemarthrosis is by a procedure known as arthrocentesis, where the fluid inside the joint is examined. Lipohemarthrosis refers to a situation where both fat and blood are present in the joint space.

What Causes Hemarthrosis?

Hemarthrosis, or bleeding into joint spaces, can be caused by a variety of diseases and disorders. These can be grouped into three main categories: traumatic, non-traumatic, and postoperative. The most common cause of hemarthrosis is traumatic injury.

Hemarthrosis can also occur without any trauma. This non-traumatic hemarthrosis can be as a result of inherited or acquired bleeding disorders. Inherited blood disorders include conditions like hemophilia and other diseases where the body lacks some blood clotting factors because of a gene mutation. Acquired bleeding disorders, on the other hand, can be a result of severe liver or kidney disease, deficiency of vitamin K, complications of medication that prevents blood clotting, and a severe condition known as disseminated intravascular coagulation. Some less common reasons for this kind of hemarthrosis include:

• Neurologic (related to nerves): Disorders like reflex sympathetic dystrophy or diabetic neuropathic arthropathy (joint damage caused by nerve damage in diabetes).
• Infectious: Bacterial infections in the joints.
• Vascular (related to blood vessels): Vitamin C deficiency, ruptured peripheral artery (a major blood vessel) aneurysms, or osteoarthritis due to tears of blood vessels in the meniscus (a part of the knee joint).
• Neoplasms (tumors): Benign (non-cancerous) hemangioma of the synovium (the tissue that lines the joints), condition known as pigmented villonodular synovitis, or any cancer arising near a joint cavity or any cancer that has spread (metastasized) to this area.

Finally, there is also a type of bleeding into the joints that can occur after operations. This is regularly associated with complete knee replacement surgery, and has also been identified as a rare complication following a procedure known as arthroscopy, which is used to visualize, diagnose, and treat problems inside a joint.

Risk Factors and Frequency for Hemarthrosis

Hemarthrosis, or bleeding into joint spaces, is a condition that can affect people with hemophilia. However, it’s not known how many people with hemophilia actually end up with this condition. Some reports suggest that about half of them might experience it at some point in their lives. Additionally, if they suffer from joint trauma, their chances of developing hemarthrosis increase.

A study looking at 1,145 patients who had experienced traumatic hemarthrosis of the knee found some interesting patterns. About half of these patients had an injury to their anterior cruciate ligament (ACL), a key ligament in the knee. The number of new cases of ACL injuries each year was 77 per 100,000 people. Men had a slightly higher incidence (91 per 100,000) than women (63 per 100,000).

For patients 16 years old or younger, a lateral patellar dislocation, or a dislocation of the kneecap, was most commonly associated with traumatic hemarthrosis of the knee. This was true for both boys (39%) and girls (43%). Again, the rate of new cases each year was slightly higher in boys (113 per 100,000) than girls (62 per 100,000).

• About half of people with hemophilia may experience hemarthrosis.
• Joint trauma can increase the risk of developing hemarthrosis.
• In a study of knee hemarthrosis patients, about half had an ACL injury.
• The annual incidence of ACL injuries is 77 per 100,000 people.
• Men are slightly more likely to have an ACL injury than women.
• In children 16 and under, lateral patellar dislocation is often associated with knee hemarthrosis.
• Boys are slightly more likely than girls to experience patellar dislocation.

Signs and Symptoms of Hemarthrosis

Hemarthrosis is a medical condition that occurs when blood accumulates in a joint, often due to an injury. The swelling from this blood collection usually happens quickly within a few hours after an injury. Pain is a common symptom, but it might take a while to develop, or it may not happen at all in people with pre-existing numbness. In most cases, the movement of the affected joint is significantly reduced.

The elbow and knee are common sites for hemarthrosis. A twisted knee, for instance, is often a common cause. The ligaments and the meniscus (the cartilage in your knee) are the usual culprits, with the anterior cruciate ligament (ACL) tears being the most common. However, other injuries can cause hemarthrosis, including dislocated kneecaps and shards of broken bone.

Sometimes, fat mixed with blood, known as lipohemarthrosis, points to a significant injury within the joint or a fracture. This condition is commonly associated with fractures of the tibial plateau (the top part of your shin bone), the attachment point of the ACL in children (tibial spine avulsion), and femoral condyle fractures (end of the thigh bone). Other symptoms may include tenderness and positive tests for joint stability.

Hemarthrosis may also occur without a clear reason, or after minor trauma. In these cases, it is most likely caused by bleeding disorders like hemophilia. Hemarthrosis is actually the primary symptom of hemophilia. Severe hemophilia can cause this condition in up to 90% of patients, most notably in children between ages 2 to 3. While any joint can be affected, the knee is the most common site. Both personal and family medical history can help determine the presence of a bleeding disorder.

The symptoms of hemophilia with hemarthrosis can vary by age. Adults and older children may have an initial period of stiffness or tingling before the pain and swelling. On the other hand, infants may show signs of irritability and decreased use of the troublesome limb. Bleeding into the hip joint poses more concern due to the increased risk of bone death due to poor blood supply in the femoral head (the ball part of the hip joint). Typically, it affects one joint at a time, but it’s also possible for it to affect both at the same time.

Testing for Hemarthrosis

When you’re suspected of having a condition called hemarthrosis, which refers to bleeding into joint spaces, there are many ways to check this. A simple X-ray, a CT scan, or an MRI can be used to take a closer look at the involved joint and the surrounding bones. X-rays are usually done first, and if a fracture isn’t seen but is strongly suspected, a CT scan might be the next step. An MRI can help spot injuries to ligaments or other soft tissues that might cause hemarthrosis. An ultrasound can also be used, when contextually appropriate, to identify and describe any fluid collections within your joint.

Sometimes, a procedure known as arthrocentesis is needed for a definite diagnosis. Arthrocentesis is when a needle is inserted into a joint space to collect and analyze the fluid there. If you have hemarthrosis, the fluid removed from the joint could look red, pink, or brown. This procedure not only helps confirm the diagnosis (it tells us if it’s a simple swelling, hemarthrosis, lipohemarthrosis (a type of hemarthrosis with fat in the fluid), or septic arthritis (an infection)), but can also help ease your pain. The collection of fluid can be further analyzed by means of centrifugation (spinning at high speed) to differentiate a true hemarthrosis from other conditions.

Lipohemarthrosis, a type of hemarthrosis with marrow fat inside the joint space, usually suggests a fracture within the joint. This can be detected by all the previously mentioned methods: arthrocentesis, X-ray, CT scan, MRI, and in some cases, ultrasound. If a lipohemarthrosis shows up on an X-ray, it’s a strong indication of a break in the joint. If you have lipohemarthrosis, there’s a high chance that you might have a hidden fracture, and a CT scan should be done for further evaluation.

In short, if you’re suspected of having a hemarthrosis, be prepared for a range of diagnostic tests and procedures. This might seem like a lot of tests, but they are crucial to ensure you get the correct diagnosis and treatment.

Treatment Options for Hemarthrosis

Hemarthrosis, or bleeding into a joint space, can be treated in several ways depending on the cause. Initially, treatment includes immobilizing the joint, applying ice, and compressing the area. Pain relief medicine may be necessary, especially for patients who need x-rays or other imaging tests. Doctors can also remove some of the fluid in the joint, using a procedure called arthrocentesis, to relieve pressure and diagnose the issue.

For patients taking blood thinners, significant bleeding into a joint is uncommon. These patients usually undergo arthrocentesis without complications. However, in rare cases where the bleeding continues or recurs, doctors may recommend medications or treatments to promote clotting or reverse the effects of blood thinners. After surgery, if bleeding into the joint recurs, a certain type of procedure called revision angioplasty may be needed. In cases where a blood vessel has burst (ruptured aneurysm), treatments may include surgery or the blockage of a blood vessel (arterial embolization). For benign tumors, removal of the synovial membrane surrounding the joint through surgical or less invasive methods (synovectomy) is typically the preferred treatment to prevent further incidents of hemarthrosis.

Special care should be given to patients with hemophilia, a medical condition where the blood doesn’t clot properly, who have acute hemarthrosis. These patients should receive specific clotting factor medications as soon as joint bleeding begins, ideally within two hours of noticing the problem. If the bleeding is in the hip or in a frequently bleeding joint, or if it’s related to an injury, higher amounts of these clotting factor medications are necessary. For bleeding in other joints like the knee, elbow, or ankle, lower amounts of these medications are typically used. Antiplatelet drugs, like specific types of pain relief medication (NSAIDs), should be avoided because they can increase bleeding.

Patients with hemophilia typically don’t require arthrocentesis to diagnose joint bleeding. But if the procedure is needed to rule out an infected joint or relieve pressure from the accumulated blood, it should only be performed after the clotting factor levels have been increased. In case of repeated bleeding into target joints, a short course of anti-inflammatory drugs (glucocorticoids) may help reduce related pain and swelling, provided there’s no sign of infection in the joint. Surgery may be considered for patients with chronic inflammation of the joint lining or joint disease, including procedures to remove the inflamed joint lining or to replace the damaged joint.

What else can Hemarthrosis be?

When a doctor is trying to figure out why someone’s joint is suddenly swollen (a condition called acute joint effusion), they have to consider several other health conditions. These might look like an acute hemarthrosis where the joint is filled with blood, but are in fact something else. These conditions can include:

• Septic arthritis (an infection in the joint)
• Lyme disease
• Tuberculosis
• Gout (which involves monosodium urate crystals)
• Pseudogout (which involves calcium pyrophosphate crystals)
• Rheumatoid arthritis
• Systemic lupus erythematosus (a long-term autoimmune condition)
• Leukemia (a type of blood cancer)
• Seronegative spondyloarthropathies (other types of arthritis like psoriatic arthritis, reactive arthritis, and arthritis linked to inflammatory bowel disease)
• Osteoarthritis (the most common type of arthritis)

This is especially true when there’s no recent injury that could explain the swelling. To figure out the exact cause, the doctor might need to remove and test a sample of the fluid in the joint (a procedure called arthrocentesis), arrange for specific diagnostic imaging, and order other lab tests related to these conditions.

What to expect with Hemarthrosis

When there is sudden swelling and pain from a condition known as hemarthrosis, appropriate treatment can considerably reduce the discomfort over a few days. However, it might take several weeks for it to fully subside. Hemarthrosis is a bleeding into joint spaces, it can happen after a traumatic injury or in certain medical conditions.

In some instances where hemarthrosis is caused by a severe bone break within a joint, or by a significant injury to soft tissues, orthopedic surgery might be needed. Soft tissues are different types of tissues that surround and support your joints, like muscles, tendons, and ligaments.

After the hemarthrosis has been treated, rehabilitation is necessary to regain joint motion, carry weight, and improve muscle strength. This could be best managed with a physical therapist who is experienced in handling cases of hemophilia. Hemophilia is a medical condition in which the ability of the blood to clot is severely reduced, causing the sufferer to bleed severely from even a slight injury.

Possible Complications When Diagnosed with Hemarthrosis

Severe or frequent bleeding into the joints, known as hemarthrosis, can damage the cartilage inside the joints leading to degenerative arthritis. This is caused by the harmful effects of blood leading to an increase in synovial membrane size and the development of excessive fibrous connective tissues. Those who have hemophilia often experience these changes in their joints due to multiple occurrences of hemarthrosis. The parts that are frequently affected are called ‘target joints’.

Recurrent or extended periods of hemarthrosis can cause a long-term disabling joint disorder which affects the internal joint layout and impairs joint movement. This chronic joint disorder affects about 20% of people with hemophilia. To prevent this frequent bleeding into the joints in people with hemophilia, doctors usually administer coagulation factors as a preventive measure.

Possible Effects:

• Destruction of cartilage in the joint
• Degenerative arthritis
• Increase in synovial membrane size
• Excessive fibrous connective tissues
• Target joints in hemophiliacs
• Long-term disabling joint disorder
• Impaired joint movement

Preventive Measures:

• Administration of prophylactic coagulation factors